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Albany Practice Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 8 June 2021

We carried out an announced inspection at Albany Practice on 13 April 2021. Overall, the practice is rated as Requires Improvement.

Safe - Good

Effective – Requires improvement

Caring - Requires improvement

Responsive - Requires improvement

Well-led - Good

Following our previous inspection on 24 September and 14 October 2020, the practice was rated Inadequate overall and for providing safe, effective, responsive and well-led services and Requires Improvement for providing a caring service. We imposed 20 urgent conditions on the provider’s registration with CQC and we placed the practice in special measures.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Albany Practice on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on:

  • All key questions
  • The conditions imposed on the provider’s registration

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting some staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as Requires Improvement overall and in the effective, caring and responsive key questions and all population groups. The safe and well-led key questions are rated Good.

We found that:

  • The practice had implemented a detailed action plan and made significant progress to address many of the concerns identified at our previous inspection.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs. However, the systems and processes to improve uptake rates for cervical screening and childhood immunisations over the past two years were not effective.
  • Staff reported treating patients with kindness and respect and involved them in decisions about their care. However, feedback from the National GP Patient Survey showed patient satisfaction with the service was significantly below local and national averages. The practice was aware of this negative feedback and was in the process of addressing these concerns to improve patient satisfaction.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. However, performance data prior to the pandemic showed patients could not always access care and treatment in a timely way. This area was identified as a priority for the practice and they had implemented some changes in a short space of time.
  • The practice had recently expanded their management structure to promote the delivery of high-quality, person-centre care. As these changes were newly implemented, the practice could not yet demonstrate the impact these changes had on the service.

Whilst we found no breaches of regulations, the provider should:

  • Continue to mitigate the risks associated with fire safety and fixed electrical installation.
  • Continue to review the systems and processes to improve uptake rates for cervical cancer screening and childhood immunisations
  • Provide information on the types of appointments offered on the practice website
  • Continue to review patient feedback in all areas and develop the patient participation group
  • Enable staff to have access to a Freedom to Speak Up Guardian

I am taking this service out of special measures. This recognises the improvements that have been made to the quality of care provided by this service.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Effective

Requires improvement

Caring

Requires improvement

Responsive

Requires improvement

Well-led

Good
Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Requires improvement

Older people

Requires improvement

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement